TABLE 5.

KEY RECOMMENDATIONS FROM KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES (KDIGO) REGARDING MANAGEMENT OF CHRONIC KIDNEY DISEASE (CKD), RELEVANT TO LIVER TRANSPLANT RECIPIENTS

Disease/Complication	KDIGO Recommendation (Grade) - Native CKD
Hypertension	All adults with CKD and urine albumin excretion <30 mg/24 hours (or equivalent*) whose office BP is consistently >140mm Hg systolic or >90mm Hg diastolic be treated with BP-lowering drugs with the goal of ≤140mm Hg systolic and ≤90mm Hg diastolic (1B)
	All adults with CKD and urine albumin excretion ≥30 mg/24 hours (or equivalent*) whose office BP is consistently >130mm Hg systolic or >80mm Hg diastolic be treated with BP-lowering drugs with the goal of <130mm Hg systolic and <80mm Hg diastolic (2D)
	ARB or ACE-I therapy should be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours (or equivalent*) (1B)
	ARB or ACE-I therapy should be used in diabetic adults with CKD and urine albumin excretion 30–300 mg/24 hours (or equivalent*) (2D)
Diet	Lower salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated (1C)
	Lower protein intake to 0.8 g/kg/day in adults with diabetes (2C) or without diabetes (2B) and GFR <30 ml/min/1.73 m2, and suggest avoiding high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression. (2C). Avoid low protein intake in patients with malnutrition or at risk for malnutrition (1C)
Acidosis	In patients with CKD and serum bicarbonate concentrations <22 mmol/l, oral bicarbonate supplementation can be given to maintain serum bicarbonate within the normal range, unless contraindicated (2B)
Diagnostic imaging	All patients with GFR <60 ml/min/1.73 m2 undergoing elective investigation involving the intravascular administration of iodinated radiocontrast media should be managed according to the KDIGO Clinical Practice Guideline for AKI including: Avoidance of high osmolar agents (1B); Use of lowest possible radiocontrast dose (Not Graded); Withdrawal of potentially nephrotoxic agents before and after the procedure (1C); Adequate hydration with saline before, during, and after the procedure (1A); Measurement of GFR 48–96 hours after the procedure (1C)
	Avoid gadolinium-containing contrast media in people with GFR <15 ml/min/1.73 m2 unless there is no alternative appropriate test (1B) People with GFR <30 ml/min/1.73 m2 who require gadolinium containing contrast media should be preferentially offered a macrocyclic chelate preparation (2B)
Referral to Nephrology	Referral to specialist kidney care services for people with CKD in the following (1B): AKI or abrupt sustained fall in GFR; GFR <30 ml/min/1.73 m2 Consistent significant albuminuria (albumin/creatinine ratio ≥300 mg/g [≥30 mg/mmol] or albumin excretion rate ≥300 mg/24 hours, equivalent to protein/creatinine ratio ≥500 mg/g [≥50 mg/mmol] or protein excretion rate ≥500 mg/24 hours) Progression of CKD (a drop in in eGFR from baseline by 25% or a sustained decline in eGFR of more than 5 ml/min/1.73 m2/yr). urinary red cell casts, RBC >20 per high power field sustained and not readily explained CKD and hypertension refractory to treatment with 4 or more antihypertensive agents persistent abnormalities of serum potassium recurrent or extensive nephrolithiasis hereditary kidney disease